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GROWTH THROUGH TREATMENT, TRAINING, AND RESEARCH

FALL 2020

TRAUMATIC STRESS

CHRONICLESINSIDE THIS EDITION...

2 DIRECTOR’S CORNER

Seven months of reckoning with dual pandemics: COVID-19 and racial injustice

2 TRAINING FRONT How the Training Academy maintained its mission and mastered virtual learning

4 COMMUNITY SPOTLIGHTA conversation with the co-chairs of Social Workers Unraveling Racism

5 INTERVENTION INSIGHTSTF-CBT and childhood traumatic grief in the COVID-19 era

6 RESEARCH UPDATEStress and health disparities: probing the impact of negative police interactions

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AT THE CENTER ANTIRACISM: HOW WE BEGAN, WHERE WE ARE HEADED“To be antiracist is a radical choice in the face of history, requiring a radical reorientation of our consciousness.” How to Be an Antiracist – Ibram X. Kendi

The Center for Child and Family Traumatic Stress has always been strongly rooted in social work practice guidelines and ethics. Among them is the “person in environment” framework, which holds that “problems in living” may be socially constructed rather than pathology based, and which creates an imperative to advocate for socially just conditions. Our early program staff recognized the deleterious intergenerational effects of racial discrimination and poverty on children, families, and communities. Recent local and national events have increased our commitment to explicitly addressing the negative effects of unjust conditions on children and families.

For much of our history, the majority of our clients have been African American, reflecting the population makeup of Baltimore City. In recent years, we have had increases in Hispanic/Latino and Caucasian clients and a lower proportion of African American clients. From our beginnings we have addressed unmet mental health evaluation and treatment needs of underserved children and families in the child welfare system, who are also primarily people of color in Baltimore City. Hewing to that focus over the years, the Center developed its Therapeutic Foster Care Program and the Early Head Start Center. It also created tailored responses to child sexual abuse, physical abuse, and domestic sex trafficking; and initiated services for Spanish-speaking clients and deaf and hard of hearing families. We extended access to care through school-, home-, and community-based services, including those delivered in homeless shelters. While our primary focus has always been mental health services delivery, we have increasingly sought to address unmet basic needs – Freddie Gray One City, Many Voices.

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DIRECTOR’S CORNERNot surprisingly, the Center for Child and Family Traumatic Stress has spent the last seven months reckoning with the dual pandemics of COVID-19 and racial injustice. The traumatic disruption caused by the virus is a new experience for virtually everyone. However, for many, dealing with racial injustice in our personal and professional lives is a daily occurrence. Nationwide, the intersection of these two events has hit Black and Brown communities especially hard. We bear witness to this reality here in Baltimore City.

Significant challenge and the need for adaptation continue for staff as well as those to whom we provide services. This edition of Traumatic Stress Chronicles is focused on some of these areas. The lead article describes our 35-year journey that began with a commitment to serving under-resourced children and families, and then to ensuring that what we delivered was culturally competent. We continue the journey with the current and clear-cut realization of the need to be antiracist in our practices, procedures, and policies.

As you’ll read in Training Front, we have been successful in transforming our Trauma Training Academy to a virtual environment, which has allowed us to provide much-needed education related to managing symptoms and behaviors resulting from COVID-19 related stress. We are particularly pleased that the leaders of Social Workers Unraveling Racism agreed to be interviewed for our Community Spotlight column. This group, a committee of the Maryland chapter of National Association of Social Workers, came together after Freddie Gray’s death at the hands of police in April 2015. That date has significance for the Traumatic Stress Center as well: it is when we began to understand our need to deal more intentionally with race-based trauma. Still more heightened awareness of systemic racism in policing has followed from the murder of George Floyd that was witnessed by the entire country. In Research Update, we describe an enhancement to an existing study of stress, epigenetics, and health outcomes. The study will now gather self-report data from study participants regarding their interactions with police and the criminal justice system.

We welcome a new writer to this edition, Cynthia Rollo, LCSW-C. Cynthia has expertise utilizing evidence-based treatments with traumatized populations and is a statewide trainer in TF-CBT. In our Intervention Insights column, she describes how this treatment model can be applied in childhood traumatic grief and to ameliorate negative impacts of COVID-19 related grief.

On a personal note: these last seven months have challenged me in many ways and left me exhausted. I am extremely grateful for my leadership team as well as the staff from the Traumatic Stress Center and the other two programs that comprise our Kennedy Krieger Department. Their efforts are nothing short of amazing!

Sincerely,

■ Elizabeth A. Thompson, PhD

Last spring, as the COVID-19 pandemic began to hold society hostage with school closings, restrictions on group gatherings and businesses, and mandated self-quarantines, the Training Academy at the Center for Child and Family Traumatic Stress was forced to cancel or postpone all trainings scheduled for the months for March and April.

We were stunned briefly, but as we watched events unfold we thought about how this pandemic is a source of great stress and anxiety for individuals and communities everywhere; and how it arguably represents a new type of mass trauma, sharing many characteristics known to be specific to mass traumatic events. We could not let the pandemic bring our mission to a halt because of fear, uncertainty, and the immediate challenge of developing new protocols to assure all-round safety.

The Academy’s evolution – from a traditional format of live, in-person conferences and trainings to live, real-time, interactive Webinars and online resources – was seen as crucial. Thanks to the visionary leadership of Elizabeth Thompson, PhD, and the dedicated staff and presenters of the Training Academy, including Miguel Roberts, PhD, Jennifer M. Serico, PhD, Casey Anderson, LCPC, RPT, Sheryl Jefferson, LCSW-C, Emily Driscoll-Roe, LCSW-C, and Sarah Gardner, LCSW-C, we were able to evolve.

Jennifer M. Serico, PhD, offered a Training Academy Webinar entitled, “Trauma in Young Children: Managing Symptoms and Behaviors during COVID-19.”

TRAINING FRONT THE TRAINING ACADEMY ADAPTS IN FACE OF PANDEMIC

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Your stories are our stories, especially in times of great challenge. Please feel free to contact us about changes and events in your own

“work spaces.” Our email: TSChronicles@KennedyKrieger.org

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...TRAINING ACADEMY ADAPTS IN FACE OF PANDEMIC

APRIL 2020

By early April, staff experts at the Kennedy Krieger Institute had already figured out how the Institute would deploy telehealth technology to safely provide care and services to patients and students. With the help of these staff members, the Training Academy easily acquired a Zoom account to host virtual trainings. As Director of the Academy, I met with our previously scheduled presenters to determine which trainings could be adapted to a virtual format, and what was needed to make this transition happen successfully. A notable difference between our in-person and virtual training sessions has been session length. We decided that virtual sessions would be no longer than four hours, which we believed would aid in trainee attentiveness and retention of information. Accordingly, our typical one-day in-person training would now be split into two four-hour Zoom trainings on separate days. We also chose the Zoom polling feature and chat box as ways for participants to interact in real time with the presenter and each other.

Aware of the financial impact of COVID-19, we decided to host a free Summer Lunch-Time Webinar series, consisting of one-hour sessions focused on trauma topics and on related tips and resources for managing additional stress during COVID-19. Our targeted launch date was the end of May.

MAY 2020

Given that the pandemic was directly impacting people’s physical health and medical encounters, we placed our initial educational efforts on medical traumatic stress. Miguel Roberts, Adult Services Clinic Coordinator, who is a clinical psychologist and Veterans Affairs-certified provider for Cognitive Processing Therapy and Prolonged Exposure therapy, developed an interactive Webinar for parents, family, caregivers, and allied professionals, entitled “Strengthening Caregiver and Child Functioning during Medical Trauma Exposure.” His objectives were to aid these individuals and groups in identifying medical trauma; and to provide them with guidance and resources for managing increased stress and trauma during the COVID-19 pandemic.

The polling feature on the Zoom platform allows users to create single- or multiple-choice polling questions for attendees at a training. The polls can gather responses from the participants and share the responses live on the screen during the meeting.

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LEARNING TO ASSURE LEARNINGThe Training Academy had much to learn when we began to develop virtual trainings last spring. For example, we realized we would not be able to have a sign-in sheet for participants (for continuing education credit), and that we needed to devise a system to ensure participant attendance from beginning to end. Zoom offers this function, but most of the Kennedy Krieger accounts were being used with patients, so we encountered HIPAA-related glitches. We now use live meeting-room attendees to confirm attendance. We also learned that transition to a virtual format meant extensive use of tech support, which increased our costs.

When the Training Academy announced this Webinar for May 20, the response was immediate. Within 24 hours the event was full to its virtual capacity. The training itself received positive feedback from attendees and is the highlight our new resource page at https://www.kennedykrieger.org/patient-care/centers-and-programs/traumatic-stress-center/training/webinar-series. We offered the Webinar again on May 27, with primarily parents and caregivers. This session was also well attended and well received!

JUNE & JULY 2020

On June 29, Jennifer Serico, who is a certified Level I Parent-Child Interaction Therapy trainer, offered a one-hour Webinar for introductory or intermediate-level professionals and paraprofessionals. This Webinar, entitled “Trauma in Young Children: Managing Symptoms and Behaviors during COVID-19,” focused specifically on the presentation of trauma symptoms in children under age 6.

On July 29, Miguel Roberts and Captain Gregory Gorman, MD, MHS, the Executive Director and Designated Federal Officer of the Defense Health Board, presented a 90-minute Webinar on military and veteran families and children who have survived (and are surviving) a traumatic event. The Webinar, entitled “Understanding and Addressing Psychological Trauma in Military Families and Children,” was directed at mental health providers and other allied professionals working with these families.

COMING IN OCTOBER 2020

We will be hosting several more free Webinars through 2020, along with regular fee-based trainings — one of which will take place on October 14. This three-hour, intermediate-level Webinar, “Trauma in Young Children: Observing & Intervening to Improve Outcomes,” includes lecture, case studies, and group discussion. We hope you will join us for this and future virtual learning at the Training Academy!

■ Danielle Gregg, MA

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COMMUNITY SPOTLIGHT SOCIAL WORKERS UNRAVELING RACISM: AN INTERVIEW

How specifically did Social Workers

Unraveling Racism come about?

Sarah Frazell: The executive director at NASW Maryland put a call out in the association newsletter. The call was, ‘Hey, we’re interested in starting a group focused on racism. If you’re interested, here’s the date and time. And a bunch of people showed up!

Barbie Johnson-Lewis: I answered the call. I said ‘okay I want to be part of that group.’ And then, next thing I know, I was the committee co-chair. [smile]

What is the vision for Social Workers

Unraveling Racism?

Barbie: The initial vision was to get social workers more aware and informed about racial issues within their agencies, within their own personal lives, within themselves – recognizing their own biases and how that affects their work as social workers. That was more of my focus. Yes, to help our clients, but we need to start with social workers.

Sarah: One thing we noticed after Freddie Gray is that social workers weren’t called on by the community to help. Other professionals, other stakeholders were, but not us, and we’re in the trenches doing and seeing things in the community that other professions weren’t seeing. We’re in touch with people – people who are experiencing all different kinds of things. It was strange that the social work community wasn’t brought in to help.

You have a Facebook page and have

been holding Community Conversations

live there. In a conversation about

Freddie Gray, a panelist spoke about

how sometimes social work graduates

erroneously feel that they are ready to

address racism, bias, and social justice

issues. What are your thoughts on this?

Barbie: I think the work has to start in the social work schools so that upcoming social workers are more aware and conscious of race and racial inequity issues throughout the world. They are going to be better at advocating, making policies, and helping clients – really doing the work that we say we’re here to do. And I think that does start in schools. Supervision is another area. Finding someone who is competent in racial equality work, having their supervision or access to consult with them about your cases. That helps inform social workers and how they can use that, also, in working with their clients.

Sarah: I think about field instructors, too. When I was a field instructor, I tried to include that [racial equality work] as well. I think that field instructors play a big role in seeing if students are trained or haven’t done their own work.

What do you think about the fact that the

Maryland Board of Social Work Examiners

requires continuing education unit (CEU)

credits in supervision and ethics for license

renewal, but there is no requirement for

antiracism training?

Sarah: That’s actually something that Social Workers Unraveling Racism is working on right now, because it’s something the Social Work Board was already having some conversations around. We actually have a petition now for social workers in Maryland, and we want to see a change that would require continuing education on antiracism, for every license renewal.

What we have seen over and over is outrage

in our country following the murder

of people of color by police, and then

complacency. What is the role of social

workers in keeping up the momentum

towards social justice? And what role can

your committee play without just being

reactionary?

Social Workers Unraveling Racism is a committee of the Maryland Chapter of the National Association of Social Workers (NASW). Formed in 2015 following the killing of Freddie Gray and the subsequent Baltimore uprising, the committee works to provide knowledge and training to social workers about the impact of racism and personal bias on their work and in their agencies. I met virtually with co-chairs Sarah Frazell, LCSW-C, Barbie Johnson-Lewis, LCSW-C, and Ebony Tyler, MSW, to learn more about their mission and their involvement in current events.

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BARBIE JOHNSON-LEWIS, LCSW-C

Psychotherapist at Barbie Johnson-Lewis, LCSW-C, LLC,

Baltimore

SARAH FRAZELL, LCSW-CDirector of Behavioral Health

Programs, Primary Care Coalition, Silver Spring, MD

EBONY TYLER, MSWFounder, The Basic Consulting

Company

IN CONVERSATIONwith Emily Driscoll-Roe,

LCSW-C

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Barbie: It’s about systems, right? And no one wants to give up their power. I mean that’s what it comes down to: it’s about money and power. So, if I change this, do I still get paid? Do I still have authority? Change is hard, and most often people don’t want to change, out of fear, ignorance, or whatever the issue. This is what we are working against, systems, institutions, and individuals that struggle with change, even though it is clearly needed.

Ebony Tyler: Social workers are to adhere to our Professional Code of Ethics, which requires us to incorporate our ethical principles and values into our workplaces and with the people we serve. One of the values is social justice, and I think we need to examine ourselves, our spaces, and our relationships regarding how we are ensuring this value is present, expanded, maintained. It is a professional obligation that the committee was founded on.

I am from the mindset that you can tell what people and organizations consider a priority

by (a) whether they measure it or not; (b) what they plan to do with the results of their measurements; and (c) whether they establish accountability and communicate the benefits and consequences associated with the plan. If the profession wants to move from a place of reactivity, there needs to be a strategic plan that continues to incorporate all three of these points.

Sarah: So much of the work is not glamorous. A lot of it is building relationships. It’s that really detailed work within institutions. Complacency comes sometimes because that work is tiring. People can lose interest or energy just responding to things as they happen. Pushing the envelope helps sometimes, like the name of our Community Conversations: “Five Years after Freddie Gray, What the #$&%*!* was provocative for a reason. There is a lot of wishy-washy material out there that nobody notices. So, that balance of pushing the envelope and also being willing to do that kind of behind-the-scenes unglamorous work is important, too.

What do you hope Social Workers

Unraveling Racism will have

accomplished five years from now?

Ebony: This is such a hard question. So much work needs to be done right now that it can be difficult to think about five years from now, but I would love for Social Workers Unraveling Racism to continue expanding throughout this country, and I would love for the committee to be a contributor to research in this area. I am hopeful that what we have been doing can be applied to other communities that are interested in this work.

* * *

Visit Social Workers Unraveling Racism on Facebook (https://www.facebook.com/groups/1725474197740690) to join Community Conversations or sign the petition for antiracism training for social work license renewal in Maryland.

■ Emily Driscoll-Roe, LCSW-C

INTERVENTION INSIGHTS TF-CBT AND CHILDHOOD TRAUMATIC GRIEF IN TIMES OF PANDEMIC LOSS AND STRESSTraumatic grief interferes with bereavement and may occur following the death of an important attachment figure. Trauma symptoms and maladaptive grief reactions can occur in children who have experienced a significant death under conditions that the child perceived to be traumatic (Cohen, Mannarino, & Deblinger,

2017). Not all children who have experienced a loss related to COVID-19 will develop traumatic grief or require a trauma-specific therapy. Even so, the circumstances surrounding COVID-19 may make it harder for a child or caregiver to experience the “typical” tasks associated with uncomplicated grief.

Reactions associated with childhood traumatic grief (CTG) may include

distressing feelings triggered by intrusive memories or reminders, which can lead to avoidance, numbing, feelings of guilt, unpleasant reminders of the way the person died, fears about personal safety or the safety of a loved one, and difficulty sleeping. When a child has intrusive thoughts or memories about aspects of the death – possible suffering experienced by the attachment figure, for example, or self-blame for the inability to help or be present – intrusive thoughts about the nature of the death can interfere with the child’s recollection of positive memories and characteristics of the person. A preexisting experience of traumatic loss, separation, medical trauma, or adversity could intensify the response to grief, and previous protective factors could be compromised.

Traumatic grief reactions often impact a child’s functioning across settings. Currently, the scope and intensity of COVID-19 stressors assure that internal and external reminders of loss are virtually unavoidable. We also know that in the United States, COVID-19 related stressors are worse for Blacks, Latinos, and American Indian/Alaska Natives, all of whom have disproportionately high rates of COVID-19 cases, hospitalizations, and deaths.

Circumstances around the COVID-19 pandemic may make it harder for children to experience “typical” tasks associated with uncomplicated grief. cont’d on page 8

...SOCIAL WORKERS UNRAVELING RACISM cont’d from page 4

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RESEARCH UPDATE

NEW RESEARCH ON HEALTH DISPARITIESAt the Center for Child and Family Traumatic Stress, our research focuses on the biological mechanisms by which stress gets “under the skin” to exacerbate health disparities and increase risk for negative health outcomes. Specifically, we are studying how negative life experiences can alter the functioning of genes. The Coronavirus pandemic and the recent deaths of George Floyd, Rayshard Brooks, and others have shined a harsh light on the persistence of health disparities, negative policing, and systemic racism in this country. We believe these sorts of experiences – like other, more studied life stressors – can also impact health and health disparities.

Scientists used to think of gene effects as fixed or deterministic. Over the past two decades, evidence has definitively shown that experience can affect gene function through what is referred to as epigenetic mechanisms – chemical modifications to the DNA that affect the likelihood of a given gene product being expressed. Stressful life experiences in childhood and even later in life have been associated with epigenetic modifications to genes known to

be involved in stress reactivity and brain development, as well as genes associated with risk for psychiatric disorders, substance use disorders, and a broad array of medical health problems.

The families participating in our research have completed questionnaires about all sorts of stressful life experiences – but we have never asked if they or a loved one have had negative experiences with the police or the criminal justice system. For this reason we have added to our current research asking about such experiences. Excerpts appear below.

We don’t yet have findings to report on this research into police interaction-related stressors, epigenetic changes, and health outcomes. However, we believe we are at a critical crossroads in our country, and all our work must be open to review through a social justice lens. We look forward to what we will learn.

■ Joan Kaufman, PhD

In our research on the biological impact of stressful life experiences, we have never asked our study participants questions about negative interactions with the police or the criminal justice system. We have introduced new questionnaires to better understand the frequency and nature of such interactions that occurred in the year before the child enrolled in the study was born. For example, we ask participants whether negative experiences occurred never, rarely, sometimes, or often in that year; they answer for themselves and, separately, for loved ones such as a partner, parent, or child. We also ask about incarceration and probation experiences of participants and loved ones. Participants always have the opportunity to write about their experiences in their own words. –JK

In the year before your study child was born, how often did

police or law enforcement …

Accuse you of having or selling drugs?

Pull you over for no reason while you were driving?

Stop and search you for no reason?

Assume you are a thief?

Verbally abuse you?

Physically abuse you?

Treat you unfairly because of how you were dressed?

Arrest you for something you didn’t do?

In the year before your study child was born …

Were you incarcerated at any time? Y/N

Were you on probation at any time? Y/N

Was a loved one incarcerated at any time? Y/N

Was a loved one on probation at any time? Y/N

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...ANTIRACISM: HOW WE BEGAN, WHERE WE ARE HEADED

the “problems in living” – through case management, community service, and securement of special funds and grants. ESTABLISHING CULTURAL COMPETENCE

In the 1990s, the Center launched its Cultural Awareness Committee to promote knowledge, attitudes, and skills for “culturally competent” clinical practice. The committee’s Brown Bag meetings – required for all staff – increasingly emphasized the traumatizing effects of racism-based social oppression and marginalization. With funding from the National Child Traumatic Stress Network (NCTSN) starting in the early 2000s, the Center embraced the goal of raising the standard of care for children and families affected by health and mental health care inequities and disparities. Such disparities had been well-documented in a supplement to the 1999 Surgeon General’s report on mental health (https://www.ncbi.nlm.nih.gov/books/NBK44243/). As a mental health-focused program, we at times felt out of alignment with the “disorders of the brain”-driven mission of the Kennedy Krieger Institute. But more recently, Bradley Schlaggar, MD, the President and CEO of Kennedy Krieger, spoke of the “neurodevelopmental consequences of social injustice,” which resonates fully with our mission and vision.

TURNING POINTS: 2015 In 2015, the death of Freddie Gray while in Baltimore City Police custody sparked community outrage and protests. One charge brought against a police officer was “depraved-heart murder,”

where depraved heart is considered a form of malice involving “wanton indifference to the consequences and perils involved.” It is as worthy of blame and punishment as the express intent to kill. Our families and staff lived at high emotional levels, with many distressed by the persistence of police brutality, inhumane race-related conditions, and heavy-handed control of protesters in the communities. Some in the community felt their personal safety was threatened; some felt that the police should be getting more support.

Hard questions about race-based trauma and how to address it began to surface within our program. Two of our early efforts – the murals One City Many Voices, parts I (2015) and II (2016) – helped us bring the community together to share sorrow and anger, along with hope for enduring change to the conditions faced by African American citizens of Baltimore City. While the meaning of “Black Lives Matter” was debated across the country, and even in our murals, there is no doubt that society has operated with depraved indifference towards people of color over generations.

TURNING POINTS: 2020

Early in 2020, after much reflection, the Cultural Awareness Committee decided to disband and emerge with a new purpose and name, the Coalition for Transformative Antiracism and Equity. Side by side with this development came the completion of the department’s strategic plan for the period 2020-2025, which incorporates a social justice lens. Things were moving fast; we knew by spring 2020 that the new plan would need revisions in order to be in alignment with an antiracism platform.

In June 2020, when George Floyd’s killing by police was broadcast around the world, many institutions and individuals were galvanized to push for change. The NCTSN brought to fruition its virtual summit, “Being Anti-Racist is Central to Trauma-Informed Care: From Awareness to Action.” Representing our department, members of the Coalition for Transformative Antiracism and Equity submitted a strong and effective application, which was accepted. It is clear from the first pre-work assignment for the summit that the mission and principles in our strategic plan will need to include explicit antiracism language, and that milestones and metrics must be developed as quickly as possible for specific racism goals. Our department director, Elizabeth Thompson, is a leader on antiracism and trauma care and some members of our staff have been active in antiracism efforts professionally and personally. Still, the next leg of our journey will require the work of looking inward, at the individual level and at the program level, to identify racist thinking and practices. There is a sense of urgency, especially for staff of color and their allies, who have long experienced the pain of living in racist society. For some white people, denial of racist thinking and systems is starting to break down. Meaningful change will require a collective commitment to taking care of each other and the program while searching for the antidotes to racist thinking.

■ Sarah A. Gardner, LCSW-C(Photos this page and page 1 courtesy of Sarah A. Gardner.)

Baltimore skyline from the Fairmount Campus of Kennedy Krieger Institute.

Client art (Expressive Arts Group, Biddle Street).

cont’d from page 1

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TF-CBT AND CHILD TRAUMATIC GRIEF

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is effective for addressing posttraumatic stress and maladaptive grief symptoms in children following a death. In this application, trauma and grief components are used sequentially, in this order, to support a child to first resolve the traumatic aspects of a death and then transition to the more typical aspects of grieving. A gradual approach to exposure is used to help the child “unpair thoughts, reminders, or discussions of the traumatic death of the love one, from overwhelming negative emotions such as terror, horror, extreme helplessness, or rage” (Cohen, Greenberg, Padlo et al., 2001). Caregivers who have participated in TF-CBT have also experienced a decrease in their own trauma and depressive symptoms.

TF-CBT PROCESS AND COVID-19 RELATED GRIEF

Before determining if TF-CBT is the best fit in response to a COVID-19 loss, the clinician should conduct a thorough trauma assessment. Two free tools, the UCLA Brief COVID-19 Screen for Child/Adolescent PTSD, and the Coronavirus Impact Scale (see below), have recently been developed to assess the impact of COVID-19 on the child and family system. Developmental and cultural considerations should be part of the assessment, including how traumatic grief symptoms might manifest variably, and the traditions and rituals normally adhered to by the family for processing death and bereavement.

Psychoeducation and parenting skills are provided at the beginning of TF-CBT; these components help the child and caregiver become aware of common emotional and behavioral responses to a death of significance, feel less alone, and feel the hope of recovery from their trauma symptoms. Individualized coping skills are then developed to support the child and caregiver in building strategies to manage trauma reminders, and to discuss trauma details in the therapy. Note that children may misinterpret normal bodily reactions to stress as symptoms of COVID-19, due to some similarities in symptom profiles. Increasing children’s understanding of physiological responses to stress and trauma can help them recognize when and how to use relaxation, affect modulation, and cognitive coping skills in response to their trauma reminders.

Coping skills are built prior to the narration and processing components of TF-CBT, in which the child talks about the details, thoughts, and feelings associated with the traumatic event, and the caregiver works with the therapist in parallel to prepare for the child’s sharing. Narration aims to help the child express distressing thoughts and feelings to their caregiver; the goal is for the child to continue to see the adult as a supportive resource in the future.

After the traumatic aspects of the death are addressed, the grief-focused components of TF-CBT are utilized. These include grief psychoeducation; grieving the loss and resolving ambivalent feelings about the deceased; preserving positive memories; redefining the relationship; and committing to present relationships (Cohen, Mannarino, & Deblinger, 2017).

An important note: The fact that exposure to COVID-19 related stressors is virtually universal at this time means that clinicians providing TF-CBT to a child or family who experienced a traumatic loss may be experiencing their own pandemic-related stress, perhaps related to death. Accordingly, awareness of this risk and the clinician’s ability to access support in the workplace are crucial.

■ Cynthia Rollo, LCSW-C

UCLA Brief COVID-19 Screen for Child/Adolescent PTSD ©. 2020.https://istss.org/clinical-resources/assessing-trauma/ucla-ptsd-assessment-tools

Kaufman, J., and Stoddard, J. Coronavirus Impact Scale. 2020. The NIH Office of Behavioral and Social Sciences Research (OBSSR). https://obssr.od.nih.gov/

...TF-CBT AND CHILDHOOD TRAUMATIC GRIEF

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COVID-19 related changes to family routines, roles, safety precautions, and skill requirements (such as virtual work and learning) can increase stress to the parent-child relationship and should be considered as part of the TF-CBT work. The National Child Traumatic Stress Network (NCTSN) and its community partners have developed tools that can be employed in the course of therapy in such times. Among the tools are:

■ Helping Children with Traumatic Separation or Traumatic Grief Related to COVID-19

■ The Power of Parenting During the Covid-19 Pandemic: Addressing Fears and Feelings from Prior Losses

■ The Power of Parenting During the Covid-19 Pandemic: Mourning the Death of a Loved One

For these and other NCTSN resources on COVID-19 and traumatic grief, visit https://www.nctsn.org/what-is-child-trauma/trauma-types/traumatic-grief/nctsn-resources

Children’s understanding of physiological responses to stress and trauma can help them recognize when and how to use coping skills in response to trauma reminders.